EJVES Extra 7, 5254 (2004)

doi: 10.1016/j.ejvsextra.2004.02.002, available online at http://www.sciencedirect.com on

SHORT REPORT

Use of a Self-retaining Retractor for Minimally Invasive

Approaches to the Aorta
W. Robb, M. C. Barry*, R. Osman, J. ODonnell, D. Logan, A. Ireland and
D. Bouchier Hayes
Department of Surgery, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin, Ireland
Key Words: Minimally invasive surgery.

Introduction
The technique of open repair of abdominal aortic
aneurysms and aorto-iliac reconstruction has changed
little over the past four decades. Endovascular
approaches remain under investigation but are limited
by anatomical considerations and questions regarding
efficacy, safety and durability have not yet been fully
answered. Laparoscopic and laparoscopically assisted
techniques have been investigated, used alone or in
conjunction with a minilaparotomy technique.1 More
recently successful aortic reconstructions using minilaparotomy incisions of 8 10 cm without laparoscopy
have been reported.2
This report describes our preliminary experience
with a minimally invasive approach to aortic surgery
using a newly developed self-retaining retractor
(Ecotracte, Advanced Surgical Concepts, Bray,
County Wicklow, Ireland).
The retractor (Fig. 1) is composed of two plastic
rings joined by a polythene sheet. The inner ring,
placed intra-abdominally, is malleable but expands
firmly outwards to maintain its circular shape. As this
ring is flexible, it may be introduced through a small
incision with a lesser circumference. Its flexibility also
allows it to be placed precisely around the field of
dissection. The outer ring is a more rigid structure,
which remains outside the abdominal cavity and also
has the added advantage of acting as a wound
protector. Once the intra-abdominal ring is in position
the plastic sheet is drawn through the outer hoop and
*Corresponding author. Ms M. C. Barry, Department of Surgery, St
Vincents University Hospital, Elm Park, Dublin 4, Ireland.

stretched backwards over its outer circumference. This

draws the walls of the wound and the abdominal
viscera outwards and creates an open wound with
stable and wide exposure.
Case 1
A 78-year-old lady with respiratory compromise
(FEV1 1.07L) was admitted for assessment of a
5.2 cm aneurysm. Spiral CT scan showed a 5.2 cm
juxta-renal aortic aneurysm, unsuitable for endovascular repair. The patients respiratory function was
improved pre-operatively (FEV1 1.39L) with chest
physiotherapy and bronchodilators. At operation an
11 cm incision was planned based on CT scan and
physical findings. The small bowel was packed out of
the field of dissection within the abdomen using moist
swabs. The aneurysm neck was then dissected and the
iliac arteries isolated. An infra-renal clamp was placed
on the aorta and the iliac arteries were controlled with
angled clamps. The aneurysm repair then proceeded
in conventional manner using an 18 mm tube graft
anastomosed using an inlay technique (Fig. 2). Postoperatively the patient had an uncomplicated recovery.
Duration of ventilation and intensive care unit stay were
20 and 36 h, respectively. The nasogastric tube was
removed on day 2 post-operatively and oral fluids and
diet commenced.
Case 2
A 76-year-old man was admitted for repair of a 5.3 cm

15333167/040052 + 03/0 q 2004 Elsevier Ltd. Open access under CC BY-NC-ND license.

Use of a Self-retaining Retractor for Minimally Invasive Approaches to the Aorta

53

Fig. 1. The retractor is composed of two plastic rings joined by a polythene sheet. The inner ring, placed intra-abdominally, is
malleable but expands firmly outwards to maintain its circular shape. The outer ring is a more rigid structure which remains
outside the abdominal cavity and also has the added advantage of acting as a wound protector.

Fig. 2. The retractor in place during the operation described in Case 1 illustrating its use as both wound protector and
effective retractor.
EJVES Extra, 2004

W. Robb et al.

54

abdominal aortic aneurysm detected at surgery for a

caecal carcinoma six weeks earlier. At operation a
midline incision (14 cm) was used and the aortic
aneurysm repaired in standard fashion using a 24 mm
tube graft. The patient was ventilated for 15 h postoperatively and spent 18 h in the intensive care unit.
Diet was re-introduced on day 2 post-operatively and
the patient made an uneventful recovery.

Discussion
The development of endovascular and laparoscopic
techniques have challenged previously accepted
approaches to aortic surgery.1 4 Despite initial optimistic reports describing comparable and sometimes
improved outcomes following endovascular repair,
long-term results regarding safety and durability are
not yet available. Laparoscopic aortic surgery is still
undergoing development and has been shown to
reduce intra-operative fluid shifts, decrease postoperative pain and shorten intensive care unit and
total hospital stay.1 A totally laparoscopic approach is
seen as difficult by many without training in advanced
laparoscopic techniques and adds considerably to the
duration of cross-clamp time and overall duration of
surgery. Addition of a mini-laparotomy provides
greater ease of access for performance of the anastomoses.1
Recently, the use of a mini-laparotomy alone without adjunctive laparoscopy has been advanced as an
alternative to the laparoscopic approach.5 Turnipseed
et al. reported that this technique using a Buckwalter
self-retaining retractor preserved the same quality of
outcome as traditional open repair while significantly
reducing post-operative ileus, time to return to normal

EJVES Extra, 2004

diet, ICU and overall hospital stay. Furthermore, when

compared to laparoscopically aided procedures significant decreases in cost, procedure and cross-clamp
time have been reported.5
The advantages of the technique described in this
report are the speed with which the retractor can be
inserted into the abdominal cavity without the
requirement for complex assembly instructions. Furthermore, once in place, no further adjustment is
required and the operation can proceed with the aid of
one assistant. With careful pre-operative planning
using ultrasound to mark the aneurysm, the size of the
incision can be reduced to 8 10 cm. The technique
involves minimal disturbance of small bowel with its
attendant risks of peri-operative fluid loss and postoperative ileus. For the surgeon performing the
procedure only a modification of previously learned
skills is required.

References
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aortoiliac surgery for aneurysm and occlusive disease: when
should a minilaparotomy be performed? J Vasc Surg 2001; 33:
469 475.
2 Maloney JD, Hoch JR, Carr SC, Acher CW, Turnipseed WD.
Preliminary experience with minilaparotomy aortic surgery. Ann
Vasc Surg 2000; 14:612.
3 Sternbergh WC, Money SR. Hospital cost of endovascular versus
open repair of abdominal aortic aneurysms: a multicenter study.
J Vasc Surg 2000; 31:237 244.
4 Clair DG, Gray B, OHara PJ, Ouriel K. An evaluation of the
costs to health care institutions of endovascular aortic aneurysm
repair. J Vasc Surg 2000; 32:148152.
5 Cerveira JJ, Halpern VJ, Faust G, Cohen JR. Minimal incision
abdominal aortic aneurysm repair. J Vasc Surg 1999; 30:977984.
Accepted 19 February 2004